Healthcare Topics Research Articles

Evidence-Based Medicine Finds a Home on the Internet

Evidence-based medicine aids busy clinicians in dealing with the information overload created by thousands of medical publications with extremely variable content. The discipline relies on randomized clinical trials as the basic building block of medical knowledge. The evolution and maturation of evidence-based medicine can be seen in the increasing amount of easily understood information available to clinicians. McMasters University is one of the established homes of evidence-based medicine, and its web site, http://hiru.mcmaster.ca, is perhaps the best place to begin an investigation of evidence-based medicine. According to the McMaster's group, “evidence-based health care promotes the collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments and facilitate cost-effective health care.” The maturity of evidence-based health care can be appreciated by reviewing the broad and deep substance of their projects. The Cancer Care Ontario-Program in Evidence-Based Care brings this topic to oncologic care. The Guidelines Appraisal Project represents an effort to bring health care professionals together to promote the development and use of practice guidelines. The Health Evidence Application and Linkage Network (HEALNet) collaborates with health care decision-makers and other private and public sector partners to facilitate the transfer of its research to users. The McMaster Evidence-Based Practice Center is under contract with the U.S. Agency for Healthcare Research and Quality to make recommendations to governments, professional organizations, and consumers based on cost-effective analysis of health care topics. The GUIDE Project (Gaining a better Understanding of the role the Internet on Decisions based on Evidence) facilitates the identification and anticipation of opportunities and problems created by the rapid growth of the Internet. Systematic Reviews The Canadian Cochrane Network & Centre supports the Cochrane collaboration, an international organization that brings systematic reviews to clinical practice. The Cochrane Collaboration (www.update-software.com/Cochrane/default.HTM) embodies the bulk of practical evidence-based medicine available on the Internet. The Database of Systematic Reviews contains full-text articles reviewing the efficacy of health care. The articles are either systematic reviews or meta-analyses. The abstract section is open to all Internet users, and posts concise abstracts of systematic reviews by reviewers at the NHS Centre for Reviews and Dissemination at the University of York, England. This large collection of clinical abstracts is extremely useful to the active clinician. It is easy to find yourself looking at one abstract after another. The abstracts themselves could be used as handouts to give to a select group of your patients as part of your determining what the patient's preferences are. For example, it may be useful for the patient to see that the side effects of antibiotics almost negate the modest beneficial effect that antibiotics have on bronchitis. Besides allowing the clinician to practice evidence-based medicine, informed patient preference increases the likelihood of achieving high patient satisfaction. The Bandolier site (www.jr2.ox.ac.uk/bandolier) is a British site that originated in 1994 as a print publication to bring evidence-based medicine to general practitioners in Britain. Bandolier scans PubMed and the Cochrane databases for new systematic reviews and meta-analyses, and publishes interesting and sensible reviews. One of the criticisms of evidence-based medicine is that its conclusions can be misapplied if used only in the service of cost-cutting. This site was created as a reaction to societal forces in England, including the National Health Service, that apply medical tenets broadly across patient populations without regard to the uniqueness of individual patients and circumstances. Many will find their skepticism born of experience to be refreshing and the fact that their opinions are based on the science of evidence-based medicine reassuring. BestBETs' BETs (Best Evidence Topics) are produced from the emergency medicine department of Manchester Royal Infirmary, UK. The three hundred articles reviewed on the site (www.bestbets.org) are pertinent to the practice of emergency medicine. The TRIP (Turning Research into Practice) (www.tripdatabase.com) database contains information from 61 sites of high-quality information. A search for bronchitis returns 32 citations. The search returns are sorted into several categories, including evidence-based, query-answering services, peer-reviewed journal, guidelines, eTextbooks, and experimental links to clinical queries on PubMed. Bringing Research to Clinicians The Journal of Family Practice (www.jfampract.com/display_archives.asp?YEAR=POEMs) posts critical evaluations of randomized trials, systematic reviews, and meta-analyses. They have posted 95 reviews known as POEMs (Patient-Oriented Evidence that Matters.) The University of Sheffield's School of Health and related Research's Netting the Evidence (www.shef.ac.uk/˜scharr/ir/netting/net.html) has the most comprehensive set of Internet links related to evidence-based medicine. One of the main goals of evidence-based medicine is to bring good research to clinicians. The Internet provides the perfect medium for the busy clinician to access this information. You will be handsomely rewarded for familiarizing yourself with these sites.Table: Evidence-Based Medicine Sites on the Internet

From Text to Hypertext

Abstract As the health care environment constantly changes, how can faculty provide current resources to students? The answer lies in the World-Wide Web and related electronic media. The Internet has numerous articles, statistics, and commentary on health care topics and should be considered a standard for teaching, especially when the course content changes so rapidly as in health care. This article discusses how the integration of Internet technologies can dramatically impact how one teaches courses that change as rapidly as the morning headlines.

Topic selection in undergraduate medical education and relevance to general practice.

Most patients who have possibly malignant diseases are first seen by physicians not specifically trained in oncology. The cancer education that undergraduate medical students receive is frequently dominated by basic science topics, detailed staging data, pharmacology of cancer drugs, and treatment protocols. This is not in accordance with the needs in general practice. In pre-course information and correspondence with reference to the International Summer School "Oncology for Medical Students," held in Groningen, The Netherlands, it is emphasized that the Summer School focuses on cancer care in general practice. As part of the education program participants are required to prepare abstracts and posters on oncologic topics in general health care in their own countries. Despite the emphasis on cancer care in general practice and despite suggestions for topics, some students have first sent in abstracts describing basic sciences research projects. Evidently during their medical training the relevancy of cancer education to the reality of daily practice had not been taught or had already been lost. In teaching undergraduate medical students, it should be realized that the vast majority will choose non-oncology disciplines. Thus, cancer education of these students should focus mainly on clinical cancer issues that are relevant in general practice.

Researching health care topics on the Internet.

Researching health care topics on the Internet.

The problems of researching sensitive topics in health care

Studying sensitive topics in health care presents additional research problems, as Vanessa Gibson explains.

Consumer health informatics: Health information technology for consumers

Consumer health informatics represents a diverse field devoted to the development, implementation, and research on telecommunication and computer applications designed for consumers to access information on a wide variety of health care topics. This technology, both hardware and software, is part of a growing trend toward empowering consumers to take a more active role in their own health care and to provide the necessary information to enhance their decision making. Research indicates that access to health information enables patients to be more active participants in the treatment process, which can lead to better medical outcomes. This article covers the technology advances, the computer programs that are currently available, and the basic research that addresses both the effectiveness of computer health informatics and its impact on the future direction of health care. © 1995 John Wiley & Sons, Inc.

Putting the "Informed" in Informed Consent About Mammography

Few health care topics have generated as much controversy as the appropriate age for screening women by mammography. In March 1993, the report of the International Workshop on Breast Cancer Screening (7) concluded that, for women aged 4049 years, randomized clinical trials of breast cancer screening showed no mortality benefit 5-7 years after entry. The report further stated that at 10-12 years after entry, the benefits of screening for women aged 40-49 years were marginal and uncertain. The controversy became dramatically more heated in 1993 when the National Cancer Institute (NCI) issued a statement of evidence about the benefits of mammography for women of different ages that replaced the previous screening guideline. Women and their physicians were encouraged to make informed decisions about mammography. Although routine mammograms were not proscribed, the NCI no longer specifically endorsed mammograms for all women aged 40-49 years. Some recent reports have corroborated the conclusions of the workshop (2), while others have raised concerns (3). The NCI statement of evidence was released in December 1993. In the months that have followed, the general press and the medical press have been filled with commentaries, controversy, and information. Yet, this plethora of information has not necessarily led to clarification, and the challenge of informed decision making remains. Few studies have attempted to explain how women and health professionals view the screening controversy or how this controversy will affect their decisions about breast cancer screening. In one of the few reports, Sutton et al. (4) found that women wanted more information before they would be comfortable with the new evidence. Focus groups conducted among women in North Carolina confirmed that many women feel uninformed. As one woman said, They keep saying they want women to make informed decisions, but I am still uninformed. The information I need is still lacking (Bloom D, Tessaro I, Rimer B: Focus Group Report About the Screening Controversy, March, 1994, unpublished). The article in this issue of the Journal by Black et al. (5) demonstrates that the ideal of informed decision making will be difficult to achieve in the face of faulty assumptions about breast cancer risk and overestimates of the benefits of mammography. The authors show that women overestimate the probability of developing and dying of breast cancer, as well as the benefits of mammography. In fact, respondents their probability of dying of breast cancer within 10 years by more than 20-fold. Equally disturbing, they overestimated the benefits of mammography as well—by about sixfold. There were some important subgroup differences. Women who were classified as not numerate were more likely to overestimate their risks, as were women with less than a high school education. The study has some important limitations. Although the sample size is adequate for the analyses undertaken, it is a relatively small base from which to generalize. Moreover, as the authors themselves cautioned, there were no minority women and the sample was largely one of educated women. Previous studies have shown that many women, especially older women, underestimate the risk of breast cancer (6). Yet, Black et al. have performed a major service by providing insight into the challenges associated with informed decision making about mammography screening. One side of the decision-making equation—women—have been shown to overestimate the risks associated with breast cancer and the benefits of mammography. It would be useful to know if physicians and other health providers have similar biases. There cannot be informed decisions if the foundations of decisions are based on faulty assumptions. If women overestimate their risks, they may be more likely to seek mammograms because they view breast cancer as a greater risk than it really is. Since the harm associated with mammography often remains unclear, there also may be a bias toward mammography because the benefits of early detection are easier to understand. This bias is consistent with the belief that a test is considered effective until proven ineffective. The preference for continued use of mammography will be more pronounced, given the parallel overestimate of the benefits of mammography. An informed decision should be one that is based on a realistic appraisal of the risks and benefits of a proposed intervention, and it should be autonomous. Mammography may be the right decision for some women but not for others. As Penman et al.

Predictions of the public agenda from television coverage

This study develops a methodology to show how German TV news in 1986 could be used to predict time trends in the public agenda for energy supply, health care, and other topics. A major influence in that year was the Chernobyl accident in the former Soviet Union. The direct result was an increase in agenda concern for energy supply. The findings showed how coverage of that incident and other issues exerted a combined influence on the public agenda.

ALTERNATIVE MEDICINE IN WESTERN INDUSTRIALIZED COUNTRIES: AN AGENDA FOR MEDICAL GEOGRAPHY

The range of health and health care topics amenable to geographical analyses in Western industralized countries has increased tremendously in the past two decades. These studies of health care systems have focused on the health organization, delivery, and utilization of biomed‐ical services, however, to the virtual exclusion of analyses of a wide variety of alternative approaches to health and healing in these countries. This lacuna is regrettable in view of the fact that people's health care behaviour suggests that medical pluralism is a persisting reality in the industrialized countries. There is indeed a coexistence of biomedicine with several alternative therapies and, in recent years, there has been resurgence in the popularity and use of alternative medicine.

The vertical file enters the electronic age.

Vertical files are revered institutions in many libraries. The reference staff at the Spencer S. Eccles Health Sciences Library at the University of Utah automated their vertical file and made the information in it accessible via the Library's Integrated Library System. Medical Subject Headings (MeSH) were applied to vertical files and simple records leading to them were entered in the Library's online catalog. Electronic access to the vertical file increases the availability of concepts too new to be in medical books and permits the Library to meet the needs of lay patrons searching for basic information on popular health care topics.

A multidisciplinary patient education workshop to integrate staff training with program development

A four session multidisciplinary workshop was held to teach Veterans Administration (VA) Medical Center staff basic patient education design principles. During the sessions, staff, working in teams, designed patient education programs on a wide variety of health care topics. Guidance to teams was provided at each step of program development so that at the end of the workshop, programs were ready for implementation. Medical Center standards for patient education and documentation were integrated into program designs.

Health activities of the U.S. Office of Technology Assessment.

The Office of Technology Assessment (OTA) was formed as part of the US Congress of 1972. The 'Health Program' was established in 1975. The purpose of the OTA is to advise Congress on the positive and negative implications of technological change. Since its beginning, the Health Program has spent most of its effort in describing technology assessment in health care and federal policies toward such assessment. A number of specific medical technologies have also been evaluated. Reports on health-care topics by the OTA have had some specific effects in Congress, but the more important impact is probably on the broader climate of opinion concerning medical technology and its benefits, risks, and costs. Technology assessment has become an established part of the Congressional decision-making process and is being used increasingly in countries other than the United States.